gastric cancer and management ppt for nurses and.pptx

gastric cancer and its management

1. Gastric Cancer(GC)

2. Stomach Hollow organ in the upper abdomen, under the ribs 5 layers: Inner layer – where most stomach cancer begins Submucosa – support tissue for the inner layer Muscle layer – create a rippling motion that mixes and mashes food Subserosa – support tissue for the outer layer Outer layer ( serosa ) – covers the stomach and hold it in place

3. What is gastric cancer ? Stomach cancer is the abnormal growth of cancerous cells in the stomach lining. This type of cancer is difficult to diagnose since many people do not exhibit any stomach cancer symptoms until it progresses to its late stages.

4. Napoleon He conquered the larger part of Europe, but he could not conquer gastric cancer Napoleon‘s gastric cancer ： Tumor found on the lesser curvature of the stomach

5. Epidemiology Fourth most common cancer In terms of geographic distribution, high rates apply to Japan, China and Eastern Europe and low rates to North America. Men > women Most are elderly at diagnosis. Median age 65 years

6. Types of gastric cancer

7. Benign and malignant tumours Benign tumors Epithelial Mesenchymal tumors Malignant tumors 1.Primary 2. Secondary: invasion from adjacent tumors.

8. Primary malignant tumours Adenocarcinomas  – Adenocarcinomas build within the cells of the inner mucosal lining of the stomach. Most stomach cancers fall into this category. Lymphoma   – When cancer cells grow abnormally in lymph tissues located in the stomach, it is referred to as ‘Lympho ma

9. Gastrointestinal Stromal Tumors  – This is a rare type of stomach cancer found in a special cell in the lining of the stomach which develops through digestive tracts. Carcinoid tumours – When cancer begins in cells of the stomach which are responsible for secreting hormones, this leads to the formation of tumours which are known as carcinoid tumours .

10. Early gastric cancer Defined as a tumor confined to the mucosal or sub mucosal layer, with or without lymph node metastasis

11. Advanced gastric cancer Invasion depth beyond sub mucosal layer

12. Bormann classifications Gross classification Polypoid type Ulcerative type Infiltrative ulcerative Diffuse infiltrative type

13. Bormann classifications Histology classification Adenocarcinoma occupy 95% Lymphomas 2% Carcinoids 1% Adenocathomas 1% Squamous cell 1%

14. Etiological Factors of Gastric Cancer H.pylori Precancerous changes Genetic factors Diet

15. Helicobacter Implicated as precursor of gastric cancer. H. Pylori associated with tumors of antrum , body and fundus of stomach,but not in cardia .

16. Diet Certain diets such as： Rich in pickled vegetables, salted fish, excessive dietary salt, smoked meat. A diet that includes fruits and vegetables rich in vitamin C may have a protective effect.

17. Genetic factors Poorly understood The majority of gastric tumor are sporadic in nature

18. Precancerous changes Precancerous diseases Chronic atrophic gastritis Gastric ulcer Gastric polyps Gastric remnant - stomach cancer can develop, usually years following distal gastrectomy or gastroenterostomy Precancerous lesion Atypical hyperplasia Gastric mucosal hypertrophy

19. Risk factors Smoking Hereditory Diet low in fruits and vegetables Alcoholism

20. Pathophysiology

21. Normal Diet low in vitamin C, E High salt diet Helicobacter pylori Intestinal metaplasia Atrophic gastritis Chronic superficial gastritis Dysplasia Cancer Peptic ulcer disease

22. TNM classification T - Primary tumor: depth of tumor invasion Tx - cannot be assessed T0- no evidence Tis - carcinoma in situ, no invasion of lamina T1- invades lamina propria or submucosa T2- invades muscularis or subserosa T3- penetrates serosa , no adjacent structure T4- invades adjacent structures- Direct extension into omentum , pancreas, diaphragm, transverse colon, and duodenum.

23. TNM classification N -Regional Lymph Nodes NX- cannot be assessed N0- no nodes N1- mets in 1-6 regional nodes N2- mets in 7-15 regional nodes N3- mets in more than 15 regional nodes Abundant lymphatic channels in sub mucosal and sub serosal layers allow for easy spread

24. TNM classification M-Distant metastasis MX- cannot be assessed M0- no distant metastases M1-distant metastases

25. Spread Patterns Direct invasion Lymph node dissemination Blood spread Intra peritoneal colonization

26. Terms related to gastric cancer Blumer shelf A shelf palpable by rectal examination, due to metastatic tumor cells gravitating from an abdominal cancer and growing in the recto vesical or recto uterine pouch Krukenberg tumor A tumor in the ovary by the spread of stomach cancer

27. TNM classification -staging Stage TNM Tis N0 M0 IA T1 N0 M0 IB T1 N1 M0 T2 N0 M0 T1 N2 M0 II T1 N2 M0 T2 N1 M0 T3 N0 M0 IIIA T2 N2 M0 T3 N1 M0 T4 N0 M0 IIIB T3 N2 M0 IV T4 N1-3 M0 T1-3 N3 M0 Any T/N M1

28. Clinical manifestations Asymptomatic or silent Peptic ulcer symptoms Nausea or vomiting Anorexia Early satiety Abdominal pain Gastrointestinal blood loss

29. Weight loss Dysphagia Heart burn waterbrash ( water and mucus in mouth) Erucation (acidic gastric contents in mouth)

30. Pain : It differs from that of peptic ulcer that it is not usually induced after meals but more to be induced after meat and protein meals It is not responsive to medical treatment , vomiting or alkali . It is usually due to high tone of the stomach wall or involving of nerve or peritoneum. It is visceral type of pain , vague , located in upper abdomen specially in epigastric region .

31. Mass : In epigastrium or left hypochondrium , indicate a late inoperable tumor . It is irregular , tender , mobile or fixed.

32. Linitis plastica : diffusely infiltrating with a rigid stomach Virchow’s node: left supraclavicular lymph node Sister Mary Joseph’s node: umbilical lymph node

33. Diagnostic findings CBC determining anemia, with may be caused by bleeding, liver dysfunction, or poor nutrition. Tumor markers CEA:carcino -embryonic antigen CA19-9:carbohydrate antigen CA724:carbohydrate antigen Endoscopic Ultrasonography

34. Esophagogastroduodenoscopy (EGD)

35. Diagnostic findings Biopsy needed for definitive diagnosis LFT RFT Stool examination for occult blood Radiologic diagnosis Double Contrast barium upper GI x-ray CT,MRI & US: Help in assessment of wall thickness, metastases (peritoneum ,liver & LNs) Laparoscopy: Detection of peritoneal metastases

36. Diagnostic findings Serum electrolytes. Coagulation studies.

37. Surgical treatment 1. Early staged carcinoma Reduced radical resection Laparoscopic surgery Endoscopic mucosal resection (EMR) Endoscopic submucosal dissection (ESD) 2. Advanced carcinoma: Gastrectomy Radical resection Palliative surgery

38. 1.Total gastrectomy Done for gastric cancer in the mid body & proximal part The operation is best performed through a long upper midline incision. The stomach is removed, including the tissues of the entire greater omentum and lesser omentum . The transverse colon is completely separated from the greater omentum .

39. The sub pyloric nodes, hepatic nodes and supra pyloric lymph nodes are dissected and the first part of the duodenum is divided, usually with a surgical stapler. The lymph node dissection is continued to the origin of the left gastric artery. The dissection is then continued along the splenic artery taking all of the nodes at the superior aspect of the pancreas and in the splenic hilum .

40. Gastrointestinal continuity is reconstituted by means of a Oesophagojejunostomy ( Bilroth I)with rouxen -y Roux loop. In Oesophagojejunostomy , anastomosis is created between esophagus and jejunum

41. 2.Subtotal gastrectomy Done for gastric cancer in the antral part Proximal part of the stomach is preserved, followed by reconstruction & creating anastomosis by gastrojejunostomy ( billroth II) . Anastomosis is created betweeen upper part of the stomaach and jejunum

42. 2. Radical gastrectomy Radical gastrectomy removes the spleen and the distal pancreas along with the stomach which is adequate for the clearance of the lymph nodes around the splenic artery

43. 3.D1 gastrectomy – The tumour and N1 nodes, ( perigastric ) are resected 4.D2 gastrectomy – The tumour and N1,N2 (along the hepatic and splenic arteries) nodes are resected .

44. Post-Operative Complications Immediate Leakage from duodenal stump. Secondary hemorrhage. Delayed Abdominal abscess Post prandial hypoglycemia, Dumping syndrome Pernicious anemia Anastomosis leak

45. Adjuvant therapy

46. Chemotherapy The administration of specific drugs to kill cancer cells and halt their abnormal division and growth in the stomach. The medications travel to the site of stomach cancer and destroy cells in regions they have metastasized to. There two different stomach cancer treatment options available for chemotherapy –  neo-adjuvant chemotherapy and adjuvant chemotherapy. Neo-adjuvant chemotherapy is used before surgery to shrink tumour cells for easy removal while adjuvant chemotherapy is used post-surgery to destroy any remnant cancerous cells in the stomach lining. The most widely used regimen is DDP , Oxaliplatin and Taxol

47. Radiotherapy Provides relief from bleeding, obstruction and pain in 50-75%.

48. Palliative surgery

49. Complementary and alternative medicine (CAM) Acupuncture Massage therapy Herbal products Vitamins or special diets Visualization Meditation Spiritual healing

50. Nursing management Assessment   History collection Recent nutritional intake and status, Weight gain or loss , Type of food and changes in eating habits Appetite Pain ,characteristics of pain, do foods, antacids, or medications relieve the pain. History of infection with H. pylori bacteria

51. Smoking and alcohol history Family history (any first- or second-degree relatives with gastric or other cancer). A psychosocial assessment, including questions about social support, individual and family coping skills, and financial resources Physical examination Palpate abdomen for tenderness or masses, and also palpates and percusses to detect ascites .

52. Pre operative nursing diagnosis Pain related to tumor mass Imbalanced nutrition, less than body requirements, related to anorexia Anxiety related to the disease and anticipated treatment Deficient knowledge regarding self-care activities Anticipatory grieving related to the diagnosis of cancer          

53. Pre operative care Relieving pain Administer analgesics as prescribed. A continuous infusion of an opioid may be necessary for severe pain. Assess the frequency, intensity, and duration of the pain to determine the effectiveness of the analgesic being administered.

54. Manage pain by non pharmacologic methods for pain relief Position changes Imagery Distraction Relaxation exercises (using audio-tapes) Backrubs Massage Periods of rest and relaxation.

55. Nutrition Assess the nutritional status . Encourages the patient to eat small, frequent portions of non irritating foods to decrease gastric irritation If the patient is unable to eat adequately to meet nutritional requirements, parenteral nutrition may be necessary Review the results of daily laboratory studies to note any metabolic abnormalities (sodium, potassium, glucose, blood urea nitrogen) Anti emetics are administered as prescribed

56. Informed consent and pychological support Obtain written informed consent for surgery and other treatment modalities Advice the patient about any procedures and treatments so that the patient knows what to expect. Answer to patient’s questions honestly Encourage the patient to participate in treatment decisions. Obtain written informed consent for surgery and other treatment modalities Allow patient’s to spend time with closed ones.

57. Preoperative preparation Prophylactic antibiotic Skin preparation Laboratory work up Pre anesthetic consent

58. Post operative nursing diagnosis Ineffective breathing pattern related to influence of anesthesia Acute pain related to surgical intervention Imbalanced nutrition less than body requirement related to dietary restriction Impaired skin integrity related to open abdominal surgery Risk for infection related to surgical intervention

59. Post operative care Airway clearance Maintain normal airway patency and breathing Propped up position to decrease abdominal pressure and to prevent aspiration Suctioning of tracheal and oral airways as needed

60. Continuous hemodynamic monitoring Vital signs are monitored and recorded every 30 to 60 minutes to identify signs of infection,bleeding,perforation or shock

61. Patency of naogastric tube Nasogastric tubes helps to keep the stomach compressed and reduces pressure on the suture lines. Check the patency of NG tube Assess colour , amount and odour of gastric drainage,presence of clot or bright bleeding. Normally initial drainage is bright red.It becomes greenish in next 12 to 16 hours ,then dark and becomes clear or greenish yellow over 2 to 3 days. Any change in the colour and odour indicate hemorrhage,intestinal obstruction or infection

62. Fluid and electrolyte balance Intravenous crystalloids sodium chloride, Ringer lactate administered to prevent dehydration, sodium and pottassium imbalance and metabolic alkalosis Close monitoring of intake and out put

63. Anti ulcer and antibiotic therapy To prevent infections and post operative complications Nutrition Resume oral fluids ,when gasric drainage and bowel sounds becomes normal . Initial feedings are clear liquids, progressing to full fluids and then frequent small regular diet Monitor bowel sounds and abdominal distension

64. Oral hygiene Mouth care, preventing cracked lips and dry mouth Early ambulation Ambulation stimulates peristalsis Prevention of deep vein thrombosis and pulmonary embolism Sequential compression devices Anticoagulant therapy

65. Home care Activity Walking,climbing stairs as tolerable. Avoid heavyweight lifting and hard physical activity Take adequate rest Diet Small frequent meals .More protein and less sugar diet Limit amount of liquids along with meals Vitamin B 12 ,Iron nd protein supplements Avoid milk and high carbohydrate diet to avoid triggering dumping syndrome

66. Daily incision care Wash the skin around the incision wth mild soap and water Change dressing daily. keep incision clean and dry Prefer loose fitting clothings

67. HEALTH EDUCATION Patient and family teaching will include information about diet and nutrition, treatment regimens, activity and lifestyle changes, pain management, and possible complications Demonstrate safe admnistration of enteral or parenteral nutrition Describe dietary restriction Emphasize recording of patient’s daily intake, output, and weight Explain strategies to manage pain, nausea, vomiting and other symptoms Explain signs and symptoms of wound infection, obstruction and perforation Describe follow up needs